System approach to prevent lost studies and improve radiology report turnaround time

On our picture archiving and communication system worklist, there was no way to differentiate body imaging (BI) from musculoskeletal (MSK) MR pelvis examinations. They were listed on only the BI worklist. This resulted in 'lost' MSK MR pelvis studies with high report turnaround time (TAT). Some exams had preliminary reports with substantiative changes made days later when found. The goals of this project were to create a solution to prevent 'lost' exams and improve TAT.

A report of 3 months of MR pelvis studies was reviewed to determine time to first view by MSK radiologists, time of completion, time of preliminary report and time of final signature. Mean TAT was calculated and exams with delays in reporting resident misinterpretation recorded.An MSK reserve flag was created for the BI radiologists to use when they found an MSK study on their worklist. The flag moved them onto the MSK reserve worklist. A second intervention included technologists placing the reserve on examination completion. After this, another 3 months of data was analysed.

There was a significant improvement (p=0.0018) in time to view by MSK from preintervention mean of 1125 min (n=107) to postintervention mean of 526 min (n=127). There was also a significant improvement (p=0.0033) in time to view inpatient and Emergency department cases from 927 min to 357 min. Time from study completion to final signature also improved from a mean of 1764 min to 838 min, though not statistically significant (p=0.08). There were five cases of delay in reporting resident misinterpretation preintervention and none postintervention.

Our intervention shows the importance of modifying human and informatics factors to solve a patient safety issue.